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References
Haifa Tawfeek, Shalan A. Al-Mashikhi, and Amer Salom
Haifa Tawfeek is affiliated with the Medical Institute in Bab-Al-Muadam, Baghdad, Shalan A. Al-Mashikhi is affiliated with the Agricultural College in the University of Baghdad, and Amer Solem is affiliated with the Institute of Nutrition Research in Baghdad.
Abstract
This study is part of a national nutrition survey conducted in Iraq during 1992 and 1993. Anthropometric measurements were obtained in 3,616 children under five years of age. Of those children, 24% were diagnosed as moderately undernourished and 6% as severely undernourished by mid-upper-arm circumference measurements. According to weight-for-height, only 11% were diagnosed as moderately undernourished and 3% as severely undernourished. The discrepancy between the results of these two measurements can be minimized by establishing a new cut-off level for mid-upper-arm circumference for defining malnutrition in our population.
Introduction
Under the long economic blockade of Iraq, poor nutrition and undernutrition have become most common and severe among infants and young children [1-3]. Many anthropometric measurements are used to evaluate the nutritional status of a population [4, 5]. The most commonly used measurements to assess the severity of undernutrition are weight-for-age, height-for-age, and weight-for-height [6, 7].
Mid-upper-arm circumference (MUAC) has been shown to be correlated closely with clinical and other anthropometric indicators of nutritional status [8, 9].
Materials and methods
This study was part of a countrywide nutrition survey conducted during 1992 and 1993. It focused on comparison of various anthropometric measurements as indicators of severity of undernutrition. Details of the research design have been described elsewhere [10]. The subjects were children under five years of age attending the maternal and child health centres for preventive care or for routine immunization. The centres are part of the governmental health-care system where, among other services, immunization and some medicines are provided free. Each centre was visited on a different day, and all children attending on that day were included in the study. The survey involved 3,616 children (1,883 boys and 1,733 girls) of varying socioeconomic status.
In 1991 Iraq had a total population of over 18 million people, 8.5 million of whom were under five years of age. Approximately 70% of the people live in cities and the other 30% in rural areas [11]. Eleven of the 18 Iraqi governorates were chosen for the study: Baghdad, Mousel, Basrah, Dialah, Al-Anbar, Wasit, Babil, Kerbala, Al-Quidisia, Theqar, and Al-Aumara. The other seven were excluded because of transportation difficulties and low population density.
Information on the infants was obtained by detailed interviews with the mothers. Age was determined to the nearest month from the birth certificate. Supine length was measured on a special board to the nearest millimetre for children up to 24 months of age. For those 24 months or more of age, standing height (without shoes) was measured to the nearest millimetre on a portable measuring board or using a tape secured to a wall or flat surface. Weight (in light clothing) was measured to the nearest 100 g, using a baby balance scale for infants and a Salter hanging scale for older children. MUAC was measured with insertion-style arm tapes at the midpoint of the child’s left upper arm [12] according to the recommendations of the Committee on Nutrition Advisory to the Centers for Disease Control [13].
The scales were calibrated daily, and the standardization was rechecked at the completion of the fieldwork. The interviews with the mothers and the anthropometric measurements were carried out by a physician and a nutritionist under the supervision of the authors to assure consistency in the data. The anthropometric indices used to identify malnutrition were weight-for-age, weight-for-height, and height-for-age Z scores. Each anthropometric index was categorized as mild (-1 to -2 SID), moderate (-2 to -3 SID), or severe (< -3 SD) [14]. The cut-off points used to identify undernourished children were < 13.5 and < 12.5 cm for moderate and severe malnutrition, respectively [9].
The significance of the comparison was assessed by Student’s t test, and associations between measurements were evaluated by correlation analyses.
Results
The correlation coefficients between different anthropometric measurements are shown in table 1. There was a highly significant correlation of about +0.88 between weight and height (p <.001). Weight and MUAC were positively correlated (r =.61; p <.05).
Table 2 shows the discrepancies between assessments based on weight-for-height and those based on MUAC for moderate and severe malnutrition. Only 11% of the pre-school children were below 2 SID of standard weight-for-height, but 24% had MUAC less than 13.5 cm. Of the children with MUAC less than 12.5 cm (6%), only 3% were below 3 SID of weight-for-height.
Figure 1 shows the prevalence of malnutrition in the children based on two different indicators. MUAC identified a higher percentage of moderately or severely undernourished children among one- to three-year-olds than among three- to five-year-olds.
Discussion
Weight-for-height and MUAC are two commonly used methods for assessing undernutrition in children under five years of age. Shakir has reported that 90% of the children in Baghdad whose arm circumference was less than 75% of the standard also had body weights less than 60% of the Harvard standard [7].
We, however, found a disagreement between estimates of undernutrition based on weight-for-height and those based on MUAC. A limit of 13.5 cm was suggested by Shakir and Morley [9] for identifying children with mild to severe malnutrition. In our population, the 13.5 cm cut-off point was too low to detect mild undernutrition as judged by weight- for-height.
The discrepancies between < 2 SD weight-for-height and < 13.5 cm MUAC values were evident because fewer children had weights less than 2 SID of their height, i.e., estimates of undernutrition based on MUAC measurements were greater than those based on weight-for-height. The same problem was faced by Ritmeijer in Myanmar. Reducing the MUAC cut-off to 13.0 cm improved the positive predictive value for weight-for height < 75%, but it still remained poor [15]. The results of a study in Indonesia suggest that a single cutoff point of MUAC 13.5 cm cannot be used for screening all children under five years of age for moderate malnutrition, but the cut-off point should be elevated with increasing age of the children [16]. Our important differences were more evident in the age-specific groups. The disagreement was higher in one- to three-year-old children than in three- to five-year-olds. A recent World Health Organization Expert Committee concluded that the pattern of mid-upper-arm growth is not age independent [17] and that the proper interpretation of MUAC requires the use of MUAC-for-age references for children aged 6 to 60 months [18]. Our data con firm that MUAC is not an effective indicator for wasting in our population unless new cut-offs are applied.
Table 1. Correlation between different anthropometric measurements for Iraqi pre-school children
|
Indicator |
Wt/age |
Ht/age |
Wt/ht |
Ht |
Wt |
MUAC |
|
Wt/age |
1 |
|
|
|
|
|
|
Ht/age |
0.72 |
1 |
|
|
|
|
|
Wt/ht |
0.79 |
0.81 |
1 |
|
|
|
|
Ht |
0.73 |
0.82 |
0.81* |
1 |
|
|
|
Wt |
0.8 |
0.73 |
0.78 |
0.88** |
1 |
|
|
MUAC |
0.58 |
0.42 |
0.60* |
0.41 |
0.61 |
1 |
Table 2. Comparison of weight-for-height and mid-upper-arm circumference as indicators of malnutrition
|
Indicator |
Moderate malnutrition |
Severe malnutrition |
|
Wt/ht |
< 2 SD N = 390 |
< 3 SD N = 90 |
|
MUAC |
< 13.5 cm N - 858 |
< 12.5 cm N = 232 |
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